Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Date of Incident:
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Classification:
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Submitted to Safety
Incident must be reported immediately. If possible, pictures must be collected to submit to insurance or other parties. Report must be submitted to the Safety Office. A complete accident investigation must be performed by a representative delegated by Brandt's Safety Director.
Employer
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Location Name (Branch):
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Location Address:
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City:
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State:
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Zip Code:
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Location Name (Branch):
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Location, if different from mailing address (Jobsite Address):
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City:
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State:
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Zip Code:
Responsibility:
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Name:
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Time in Trade:
- 0 - 3 Months
- 4 - 9 Months
- 10 Months - 2 Years
- 2 - 5 Years
- 5 - 10 Years
- More than 10 Years
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Home Address:
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City:
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State:
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Zip Code:
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Phone:
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Date of Birth:
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Trade and Classification:
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Project Manager / Superintendent:
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Employee Job Description:
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Time With Brandt:
Incident Information:
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Where Did Incident Occur? (Number & Street, City)
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State:
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Zip Code:
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County:
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On Employer's Premises?
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Job Number:
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Phase of job:
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What was person doing when accident occurred? ( Be specific, identify tools, equipment, or material employee was using)
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How did the incident occur? (Describe fully the events that led up to the accident. Tell what happened and how it happened.)
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Describe in full damages or consequences of the incident:
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Date of Incident:
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Time of Day:
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Were there injuries associated with the incident?
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If yes, was a separate Injury Report submitted?
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Date Employer Notified:
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Who Was Notified? (Name)
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Names and Classifications of Witnesses:
Accident Causes and Corrections:
The supervisor of the employee shall investigate the incident at once and complete all items below:
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Check one or more causes that contributed to incident
- Faulty Equipment
- Job Planning or instruction inadequate
- Rules or procedures not followed or inadequate
- Incorrect Body Position
- Incorrect tools or equipment used
- Guarding or protective devices not provided or ineffective
- Plant equipment operated incorrectly
- Housekeeping congested, incorrect storage
- Maintenance, inspection not adequate
- Incorrect, or lack of PPE
- Inadequate training
- Chemical exposure, personal hygiene
- Improper vehicle operation
- Environmental factors, weather
- Animal, reptile or insect
- Inattentive to details of job
- Action of fellow employees
- Other
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Indicate primary incident cause, and explain reason selected:
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Check one or more actions that will prevent a recurrence
- Provide more complete job instruction
- Review job planning, regulate job pace
- Update or revise procedures
- Enforce work rules, revise standards
- Provide safe equipment
- Provide proper tools and equipment
- Reinforce employee training
- Provide PPE
- Modify plant or equipment
- Contact third party to effect correction
- Other
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Indicate primary corrective action, and explain reason selected:
Follow Up:
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What corrective action is required?
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Completion date for corrective action:
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Person in charge of corrective action:
Review:
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Prepared By:
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Reviewed By:
Photos of Incident:
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#1
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#2
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#3
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#4
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#5
